Hockley Farm Medical Practice

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved patients in decisions about their care and treatment and provided them with advice and support. Staff routinely reviewed patients care and worked with other services to achieve this.

At our previous comprehensive assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice had systems and processes in place to identify patients’ needs and preferences during the registration process. The practice used digital flags within the care records system to highlight any specific individual needs such as the requirement for longer appointments or for a translator to be present.

Staff checked patients’ health, care, and wellbeing needs during health reviews. Clinicians used templates when conducting reviews to support the assessment of patients’ wider health and wellbeing. Staff could refer patients with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

As part of our clinical searches, we reviewed the care of patients with hypothyroidism (underactive thyroid). We identified 329 patients who were diagnosed with hypothyroidism of which 6 patients were found to be potentially overdue thyroid function blood test monitoring. We reviewed in detail the records of 5 of these patients and subsequently found issues with the care of 1 of these patients who was overdue a thyroid function blood test and had been invited for an appointment but not attended; and had not been short-scripted the medication. The practice took immediate action in response to our feedback and undertook an audit of all patients with a diagnosis of hypothyroidism without a thyroid function blood test result recorded within the preceding 18 months. Learning from this audit included the implementation of a 6-monthly hypothyroidism audit to be added to the practice's standing audit schedule and the findings and outcomes of each audit cycle to be reported to the practice's clinical governance/significant event meeting.

We also reviewed the care of patients with diabetes. We identified 154 patients with diabetes whose last HbA1c reading was over 75 mmol/mol. We reviewed in detail a random sample of 5 patient records and found 2 patients had not had their diabetes and diabetic medication reviewed since this raised blood glucose result. The practice took immediate action in response to our feedback and undertook an audit of all diabetic patients with a HbA1c reading over 75 mmol/mol. Learning from this audit included the implementation of an immediate workforce intervention which involved a supervised complex-diabetes mop-up clinic to be run by an upskilled GP resident. In addition, leaders told us the practice was investing in longer-term specialist capacity such as a nursing lead with an MSc qualification in diabetes.

The National GP Patient Survey found 82% of patients felt their needs were met during their last general practice appointment which was slightly below the national average of 90%.

There were systems in place for staff to keep up to date with relevant legislation, evidence-based practice and required standards. Clinical meetings were in place and for clinicians who were unable to attend this meeting in person, these meetings were minuted and disseminated to all clinicians.

The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

For example, we identified 43 out of 1241 patients on the asthma register had been prescribed 2 or more courses of rescue steroids (Prednisolone). We reviewed a sample of 5 patient records and found all 5 had received an adequate assessment at the time of the prescribing of the rescue steroid. However, we found none of the 5 patients had been followed up to check their response to treatment in an appropriate timescale following the acute exacerbation of their asthma. National Institute for Health and Care Excellence (NICE) guidance recommends that patients receive a follow up within two working days. The practice took immediate action in response to our feedback and undertook an audit of all patients prescribed oral corticosteroids for asthma exacerbation over the past 12 months without a documented follow-up review within 2 working days. Learning from this audit included the introduction of an automatic prompt for the prescriber on the clinical system to schedule a follow-up appointment 2 working days later for the patient. Leaders also arranged for a follow-up audit within 3 months to confirm the effectiveness of this intervention.

As part of our clinical searches, we identified 52 patients with chronic kidney disease (CKD) Stages 4 or 5. Of these 52 patients, we identified 8 patients who had not had the required blood tests in the last 9 months. We looked in detail at the patient records of 5 patients and found 3 patients had not had their CKD stage correctly updated in their patient records; we also identified 1 patient who was incorrectly coded on the clinical system as having Stage 4 CKD, however this patient did not have chronic kidney disease. The practice took immediate action in response to our feedback and undertook an audit of all patients coded with CKD Stages 4 or 5. Learning from this audit included the introduction of a 3-monthly recurring audit of all CKD patients to proactively identify those due monitoring or a referral, appropriate to their disease stage.

The practice worked well across teams and services to support patients. They made sure patients only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to information they needed to assess, plan, and deliver patients’ care, treatment, and support. Systems were in place to share information about patients electronically with other services.

The practice worked with other services to ensure continuity of care and engaged in multi-disciplinary team (MDT) meetings. For example, for patients identified as approaching end of life, the practice referred to and worked closely with the community palliative care team. We saw evidence of staff training on forms used by GPs for sharing information if they were unable to attend an MDT meeting. Home visits and care packages were implemented to ensure patients’ wishes were followed and carried out in their final stages of life.

The practice referred patients to the additional roles reimbursement scheme (ARRS) staff such as ‘WorkWell’ coaches. WorkWell is a personalised employment support service for people whose health is affecting their ability to work.

The practice supported patients to manage their health and wellbeing to maximise their independence, choice and control. The practice waiting area and practice website provided health information for patients.

Staff supported national priorities and initiatives to improve population health, including stopping smoking, diabetes prevention programme and tackling obesity.

For example, the lead GP specialised in metabolic control, and the lead nurse assisted patients with weight management. Clinicians referred patients to the 12-week online NHS ‘Digital Weight Management Programme’ which supports adults living with obesity who also have a diagnosis of diabetes, high blood pressure, or both, to manage their weight and improve their health.

Staff also referred patients to the ‘Health and Wellbeing Coach.’ Health and wellbeing coaches support people to increase their ability to self-manage their motivation levels and commitment to change their lifestyle. They work with people with physical and mental health conditions and those at risk of developing them.

In addition to weight management, the practice supported patients to stop smoking. Smoking cessation clinics were available in the practice on a weekly basis.

For patients experiencing persistent sleeping problems, clinicians referred patients to ‘Sleep Station’ which offered digital sleep support options and used evidence-based methods, including the principles of cognitive behavioural therapy for insomnia (CBT-I). Sleep Station’s sleep support programmes are tailored to each person and may include structured support from sleep coaches, or guided self-help.

The practice routinely monitored patients care and treatment to continuously improve it. Staff endeavoured to ensure that outcomes were positive and consistent, and that they met both the clinical expectations and the expectations of patients. The practice undertook regular clinical audits, and we were provided with evidence of two-cycle audits which demonstrated quality improvement. For example, the practice had undertaken a 2-cycle audit on atrial fibrillation (a heart condition) which demonstrated a 16% improvement in anticoagulant prescribing (drugs that slow down the body's process of making blood clots).

Staff focused on identifying risks to patients’ health, including those in the last 12 months of their lives and patients at risk of developing a long-term condition.

As part of our assessment, the latest published information from the UK Health Security Agency (UKHSA) showed that the practice did not always achieve the World Health Organisation target of 95% for the number of children immunised against various infectious childhood diseases.

The percentage of children aged 5 who had received immunisation for measles, mumps and rubella (two doses of MMR) was 81%.

The percentage of children aged 2 who had received immunisation for measles, mumps and rubella (one dose of MMR) was 93%.

The percentage of children aged 2 who had received their booster immunisation Pneumococcal infection was 92%.

The percentage of children aged 2 who have received their immunisation for Haemophilus influenza type b and Meningitis C was 94%.

The percentage of children aged 1 who had completed a primary course of immunisation for Diphtheria, Tetanus, Polio, Pertussis, Haemophilus influenza type b (Hib), and Hepatitis B (Hep B) was 86%.

We asked staff what they were doing to try to improve the uptake of childhood immunisations. Staff told us about a number of initiatives which included two dedicated Patient Advisors assigned to identify children who are due or overdue vaccinations and proactively contact parents/carers by telephone to encourage uptake and invite them to book an appointment; immunisation training course for staff which focuses on improving vaccination uptake; flexible vaccination clinics scheduled on different days and across both morning and afternoon sessions; actively contacting families to offer another appointment if they did not attend; providing patient education through patient information leaflets and articles in the ‘Braunstone Alert’ local community magazine to promote childhood immunisations; and where parents decline childhood vaccinations, our nursing team will contact them to discuss their reasons for refusal, address any concerns and provide further information.

We also reviewed published national data for the uptake of cervical screening. The practice had achieved 63%, for women aged 25-49 and 69% for women aged 50-64; both significantly below the national target of 80%. The practice was working to improve the cervical screening uptake and made telephone calls to patients who failed to attend their appointments.

The practice told patients about their rights around consent and respected these when delivering person-centred care and treatment. A consent policy was in place to ensure appropriate consent was obtained from patients when receiving care and treatment. Staff understood the requirements of legislation and guidance when considering consent and decision making. We saw evidence of a training session for staff which had been arranged to review the practice’s updated chaperone policy.

Patients were offered a chaperone for care and treatment when this was appropriate. Chaperone posters were on display at the practice to inform patients of this service and staff who provided this service had completed chaperone training.